Cardiopulmonary Resuscitation in Adults Over 80

Outcome and the Perception of Appropriateness by Clinicians

Patrick Druwé, MD; Dominique D. Benoit, MD, PhD; Koenraad G. Monsieurs, MD, PhD; James Gagg, MA Oxf; Shinji Nakahara, MD, PhD; Evan Avraham Alpert, MD; Hans van Schuppen, MD; Gábor Élő, MD, PhD; Sofie A. Huybrechts, MSc; Nicolas Mpotos, MD, PhD; Luc-Marie Joly, MD, PhD; Theodoros Xanthos, MD, PhD; Markus Roessler, MD, PhD; Peter Paal, MD, MBA; Michael N. Cocchi, MD; Conrad Bjørshol, MD, PhD; Jouni Nurmi, MD, PhD; Pascual Piñera Salmeron, MD; RadoslawOwczuk, MD, PhD; Hildigunnur Svavarsdóttir, MSc; Diana Cimpoesu, MD, PhD; Violetta Raffay, MD, PhD; Gal Pachys, MD; Peter De Paepe, MD, PhD; Ruth Piers, MD, PhD

Disclosures

J Am Geriatr Soc. 2020;68(1):39-45. 

In This Article

Abstract and Introduction

Abstract

Objectives: To determine the prevalence of clinician perception of inappropriate cardiopulmonary resuscitation (CPR) regarding the last out-of-hospital cardiac arrest (OHCA) encountered in an adult 80 years or older and its relationship to patient outcome.

Design: Subanalysis of an international multicenter cross-sectional survey (REAPPROPRIATE).

Setting: Out-of-hospital CPR attempts registered in Europe, Israel, Japan, and the United States in adults 80 years or older.

Participants: A total of 611 clinicians of whom 176 (28.8%) were doctors, 123 (20.1%) were nurses, and 312 (51.1%) were emergency medical technicians/paramedics.

Results and Measurements: The last CPR attempt among patients 80 years or older was perceived as appropriate by 320 (52.4%) of the clinicians; 178 (29.1%) were uncertain about the appropriateness, and 113 (18.5%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the "appropriate" subgroup was 8 of 265 (3.0%), 1 of 164 (.6%) in the "uncertain" subgroup, and 2 of 107 (1.9%) in the "inappropriate" subgroup (P = .23); 503 of 564 (89.2%) CPR attempts involved non-shockable rhythms.

CPR attempts in nursing homes accounted for 124 of 590 (21.0%) of the patients and were perceived as appropriate by 44 (35.5%) of the clinicians; 45 (36.3%) were uncertain about the appropriateness; and 35 (28.2%) perceived the CPR attempt as inappropriate. The survival to hospital discharge for the nursing home patients was 0 of 107 (0%); 104 of 111 (93.7%) CPR attempts involved non-shockable rhythms.

Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate.

Conclusion: Our findings show that despite generally poor outcomes for older patients undergoing CPR, many emergency clinicians do not consider these attempts at resuscitation to be inappropriate. A professional and societal debate is urgently needed to ensure that first we do not harm older patients by futile CPR attempts.

Introduction

The treatment of cardiac arrest in older patients poses significant clinical and ethical challenges. Worldwide, as life expectancy increases, more people are surviving to an older age. In the United States the number of citizens aged 65 or above is projected to more than double by 2060, amounting to 24% of the total population; the number of people aged 85 or older will have more than tripled up to nearly 20 million.[1] In the European Union, the percentage of people aged 65 or above relative to those aged 15 to 64 is projected to rise from 29.6% in 2016 to 51.2% in 2070.[2] In Japan, the proportion of inhabitants aged 65 or older is estimated to increase from 26.6% in 2015 to 30.0% in 2025.[3]

As a consequence of the aging of the population, emergency medicine clinicians are confronted with a rising number of out-of-hospital cardiac arrests (OHCAs). In Sweden the incidence rate of OHCAs among people 90 years or older more than doubled between 1992 and 2013 from 112.4 to 236.0 per 100 000 person-years.[4] In Japan the incidence rate of bystander-witnessed OHCAs among persons 80 years or older increased from 463 to 522 per 100 000 persons between 2005 and 2009.[5]

Although some reports suggest that age is an independent predictor of poor prognosis,[6] the largest study of OHCA in older persons did not demonstrate a significant difference in neurologic outcome with increasing age.[4] Because the number of cardiac arrests with an initial shockable rhythm decreases with increasing age,[4,8] unfavorable cardiac arrest characteristics, together with baseline comorbidities and frailty, are probably more relevant than age itself related to the expected prognosis.[8] Most older patients have cardiac arrest characteristics that have been associated with a poor prognosis, such as non-shockable rhythms, unwitnessed arrest, or no bystander cardiopulmonary resuscitation (CPR). For example, in Japan approximately 74% of OHCA cases in patients aged 75 years or older have asystole as the initial rhythm.[3] As a result of these characteristics, the outcome of OHCA resuscitation in the older population is poor.

Nationwide CPR registries from Denmark and Sweden report a 30-day survival of OHCA among patients 80 years or older between 2.0% and 4.1%, decreasing with increasing age.[4,7] Recently reported rates of 30-day good neurologic outcome in OHCA patients 85 years or older are between .5% and 1.9%.[8,9] In Japan the improvement in favorable neurologic outcome after OHCA from 2005 to 2009 was not observed in patients 80 years or older.[5] As such, the ethical principle of nonmaleficence may be particularly relevant in this context, not only because of small chances of survival for this population, but also due to a high probability of injury during CPR and functional impairment in older people who survive an OHCA. Ethical decision making in the setting of cardiac arrest does not only include balancing benefits and harms but also entails accounting for the presumed wishes and treatment goals of patients who may attach great importance to their mental and physical abilities.[10,11] To uphold the basic principles of medical ethics, it is warranted to investigate how clinicians perceive their resuscitation practices. No large-scale studies have been conducted on how healthcare professionals think about the balance between benefit and harm of CPR in older patients.[12]

The aims of this study were to determine the prevalence of clinician perception of inappropriate CPR regarding the last (OHCA) encountered in an adult 80 years or older, and the relationship of this perception to patient outcome. Inappropriate CPR is defined as a resuscitation attempt that is disproportionate to the expected prognosis of the patient in terms of survival or quality of life.

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